NCLEX-PN
NCLEX Trainer Test 2 Questions
Extract:
Question 1 of 5
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
Question 2 of 5
The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the functioning of the client's recent memory?
Correct Answer: C
Rationale: I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen. This tests immediate recall, a component of recent memory.
Question 3 of 5
The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is:
Correct Answer: B
Rationale: Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth.
Extract:
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity.
Question 4 of 5
It is MOST important for the nurse to take which of the following actions?
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antibiotic should be administered within one hour (2) unnecessary for safe infusion (3) correct-when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion
Extract:
Question 5 of 5
The nurse is talking with an adult who says she has chronic constipation. What suggestion would probably be most helpful to the client?
Correct Answer: B
Rationale: Fruits and vegetables are high in fiber, promoting bowel regularity and alleviating constipation. Rice is low-fiber, Lomotil slows motility, and limiting fluids to meals can worsen constipation.